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JUL. 20,2007 1:55PM HRESIONE METAL PKODUCIS, LLG <br />Lt3240B Application to Conduct Excluded B <br />ChieftXec tj e. i r` igria fury <br />rheinformation provided in thi lication is c 7pl®te <br />Chief executive officer's sianstureIl <br />Name (please pri <br />Loo) : 0rilt Of' <br />On behalf of the city, l approve this application for <br />excluded bingo activity at the premises located within <br />the city's jurisdiction. <br />uu. Ym r. 1 <br />Page 2 of 2 <br />ingo 6107 <br />and accurate to the best of my knowledge. <br />Phone number — 769 - -S <br />A' <br />M <br />Print city name C <br />Signature of olty personnel receiving application <br />Tin F. I* ^C Cj � Date�Z/Zc <br />If the gambling premises Is lotion d In a township, both the county and tow"ship must sigh this application. <br />For the township; On behalf of the tovmship, <br />i acknowledge that the organization is applying for <br />excluded bingo actl�,ihr within the township limits. Print township name <br />A township has no statutory authority to approve or 5irature of township <br />deny an application (Minn, Stat. 349.213, Subd. 2). <br />For the county: On behalf of the county, I approve <br />this application for excluded bingo activity at the <br />premises located within the county's jurisdiction. <br />1�l:ail:•A,�l[3�ic�t�bri �tia�`�X,��,�t9;irit�t(s�', <br />��r0e�.rr�r —. r • - -•- - n��i1 <br />Send the application and proof of nonprofit <br />status to: <br />Gambling Control Board <br />Suite 3 00 South <br />1711 W. County fad. B <br />Roseville, Mid 55113 <br />application <br />Title Date 1 I <br />Print county name <br />Signature of county personnel receiving application <br />Title Date 1 / <br />You will receive a document from the Gambling Control Board with <br />your permit number for the gambling activity. Your organization must <br />keep its bingo records for S -9/2 years. <br />Questions? Contact the Gambling Control Board at 651- 639 -4006. <br />This form will be made available .fn alternative format (Le. large print, <br />Or, you may fax it to 851 - 63932. Braille) upon request. <br />Date Privacy Notice; The Information roquested on this form <br />(and any attachments) will be used by the Gambling Control Board <br />(Board) to determine your quatffjcations to be involved in lawful <br />gambling activities in Minnesota. You have the fight to refuse to <br />supply the information requested; however, if you refuso to supply <br />this Information, the 9oard may not be able to determine your <br />qualifications and, as a consequence, may refuse to issue you <br />an authorization. If you supply the information requested, the <br />Board will be able to proce °.o your application. <br />Your name and your organization's name and address will be <br />public information when received by the Board. All the other <br />Information will be private data until the Board issues your <br />authorization and the information then becomes public. If the <br />Board does not issue you an authorization, all information provided <br />remAfns private, with the exception of your name and your <br />organization's name and address which will remain public. <br />Private data about you is available to: Board members, Board staff <br />whose work requires access to the information. Minnesota's <br />Department of Public Safety. Attorney Gonoral: Commissioners of <br />Administration, Finance, and Revenue; Legislative Auditor, national <br />and Intemational gambling regulatory agencies; anyone pursuant to <br />court order; other individuals and agoncles that are spscificaily <br />authorized by stato or federal law to have access to the informatlon: <br />individuals and agencies for which law or legal order authorizes a <br />Haut use or sharing of Information after this Notfeo was given; and <br />anyone with your consent. <br />—23 <br />